With fewer places left to turn, patients in need of mental health services are increasingly flocking to emergency departments across the country.
Explore This IssueACEP Now: Vol 33 – No 06 – June 2014
But in EDs, mental health patients are diverting attention from medical patients, tying up emergency beds for days while awaiting inpatient or community beds. They also are at increased risk of poor outcomes due to care that is delivered in a less-appropriate setting.
Nationally, there are an average of 26.1 psychiatric beds per 100,000 people, according to ACEP’s 2014 Report Card. Meanwhile, the National Alliance on Mental Illness reports 61 million Americans experience mental illness each year, but state funding for mental health continues to drop. From 2009 to 2012, states cut $1.6 billion in funding, a decrease of 10 percent.
Recently, the shortage of psychiatric beds contributed to an overall D+ grade on ACEP’s 2014 Report Card on Emergency Medicine, which ranked access to care more heavily than any other measure.
“We can do emergent care, stabilize individuals, but people need to get to the appropriate places to get the appropriate care,” said Jon Mark Hirshon, MD, MPH, PhD, FACEP, associate professor in the Department of Emergency Medicine at the National Study Center for Trauma and Emergency Medical Systems in Baltimore and the Report Card Task Force chair.
For instance, late last year, Virginia State Sen. Creigh Deeds was repeatedly stabbed by his 24-year-old son, who then fatally turned a gun on himself. Deeds’ son received an emergency mental health evaluation the day before the incident, but he was released when no psychiatric bed could be found for him.
These problems don’t typically start in the ED. Instead, they are symptomatic of larger flaws within the health care system. Dr. Hirshon recently testified at a Congressional hearing meant to address the psychiatric bed shortage.
Within two hours of the start of a recent shift, ACEP President-Elect Michael Gerardi, MD, FAAP, FACEP, an emergency physician at Morristown Medical Center and Goryeb Children’s Hospital, both in Morristown, New Jersey, had already evaluated four psychiatric patients.
He expected at least one of them would board in the ED for two or three days. In addition to a shortage of available beds and staff, he said hospitals are often reluctant to admit patients whose insurance may not pay for mental health.
This situation places EDs and hospitals at odds. EDs must treat every patient who comes through the doors. Hospitals are not bound by the same code.
Dr. Gerardi is waiting to see if the Affordable Care Act changes the game.
Dr. Hirshon said some of his colleagues report that patients have boarded between two weeks and 42 days in the ED. He said it’s going to take creative solutions to solve this problem.
Nationwide, a 2008 ACEP survey showed that 99 percent of emergency physicians admit psychiatric patients each week, and nearly 80 percent report psychiatric patients are boarded in the ED.
“I think no single source is going to have all the answers,” Dr. Hirshon said. “The ED is a spot that works 24-7, 365 days a week and we’re there to help people…Our mission is to help people, but that’s problematic when they have needs that are above and beyond what we have in the ED.”
Kelly April Tyrrell is a freelance journalist based in Wilmington, Delaware.